Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists. A place to talk; no one has to listen.
All patient vignettes are confabulated; the psychiatrists, however, are mostly real.
--Topics include psychotherapy, humor, depression, bipolar, anxiety, schizophrenia, medications, ethics, psychopharmacology, forensic and correctional psychiatry, psychology, mental health, chocolate, and emotional support ducks. Don't ask. (It's not Shrink Wrap.)

Wednesday, May 18, 2011

Aloha from the American Psychiatric Association's Annual Meeting in Honolulu! The weather is gorgeous here and it's been a great meeting. Yesterday, I heard Archbishop Desmond Tutu speak, and today, I listened to "Conversations" with Lorraine Bracco--also known as Dr. Melfi from The Sopranos. The beach is nice, too, and Clink has been scuba diving. Should I tell you she just learned to swim this past winter? She is amazing!

In a few hours, we will be giving our workshop, The Accessible Psychiatry Project: The Public Face of Psychiatry in New Media. We are telling the audience that the survey we did was not validated, was not statistically analyzed, and is not real science. Mostly, it was about how cool it is that we can even do this at all (ask questions, interact with readers, have an impact). I thought I'd share the survey results with everyone here. If you took the survey, thank you, again.

702responses

Summary

Who are you?

A professional who treats psychiatric disorders (for example, a mental health professional, a primary care physician/ nurse practioner, or pediatrician)

129

19%

Someone who works in a field connected to psychiatry, for example a researcher, health writer, clergyman, patient advocate, support staff in a mental health facility

100

15%

Someone who is or has been in treatment for a mental illness

410

60%

The family member or close friend of someone with a psychiatric disorder

256

38%

The family member or close friend of a mental health professional

96

14%

An innocent bystander with no direct relationship to the mental health profession

63

9%

Other

79

12%

People may select more than one checkbox, so percentages may add up to more than 100%.

My age group - Choose one

Under 20

20

3%

21-35

251

36%

36-50

225

32%

51-65

163

23%

Over 65

20

3%

People may select more than one checkbox, so percentages may add up to more than 100%.

My perception of psychiatry has been primarily shaped by . . .

My personal experiences as either a professional in the field or as a patient

550

81%

The experiences of those close to me

291

43%

The portrayals I see in the media

117

17%

Information I have read about psychiatry

337

49%

I don't have any preconceived ideas about psychiatry

17

2%

Other

32

5%

People may select more than one checkbox, so percentages may add up to more than 100%.

I believe that psychiatry . . .

more often than not helps people with mental health problems

448

66%

more often than not harms people with mental health problems

77

11%

encourages people to use diagnostic labels to explain their bad behavior or laziness

119

18%

provides explanations for behavior in a way that is ultimately helpful

338

50%

is a field that is about controlling others and is basically evil

36

5%

is a field that is about helping those with mental disorders to live better lives

467

69%

Other

181

27%

People may select more than one checkbox, so percentages may add up to more than 100%.

Psychiatric patients, in general, ...

are just regular people

524

78%

are more creative and/or interesting than the average person.

125

19%

are uncomfortable to be around

79

12%

are often dangerous or scary

32

5%

are unreliable

55

8%

should not be permitted to work in certain professions, such as medicine, child care, or law enforcement

33

5%

live better lives if they hide the fact that they suffer from mental illness

151

22%

live better lives if they are open with the fact that they suffer from mental illness

221

33%

Other

157

23%

People may select more than one checkbox, so percentages may add up to more than 100%.

Psychiatrists are . . .

interesting people

284

43%

weird people

146

22%

intimidating because they may analyze me in public settings or know what I'm thinking

49

7%

on the whole, no different than any other group of professionals

317

47%

pawns of the pharmaceutical industry

159

24%

interested in knowing and understanding their patients as complete human beings

280

42%

just interested in symptoms and medications

215

32%

troubled people looking to cure themselves

64

10%

I have no opinion about psychiatrists

26

4%

Other

166

25%

People may select more than one checkbox, so percentages may add up to more than 100%.

Have you ever been evaluated or treated by a psychiatrist? -

Yes

447

64%

No

215

31%

People may select more than one checkbox, so percentages may add up to more than 100%.

Psychotherapy . . .

more often than not helps people recover from or manage mental illness

417

62%

more often than not helps people to better understand themselves and negotiate their lives

457

68%

encourages a detrimental, self-centered perspective

50

7%

more often than not makes people feel or behave worse than they did before they entered treatment

23

3%

is for people who don't have friends to talk to

56

8%

is more often than not inferior to medication as a treatment for mental disorders

54

8%

is more often than not superior to medication as a treatment for mental disorders

176

26%

does nothing

29

4%

I have no significant opinion about psychotherapy

45

7%

Other

154

23%

People may select more than one checkbox, so percentages may add up to more than 100%.

Have you ever been in psychotherapy? -

Yes

486

69%

No

176

25%

People may select more than one checkbox, so percentages may add up to more than 100%.

Psychiatric medications . . .

more often than not help people recover from, or cope with, their difficulties

368

55%

more often than not cause problems that are worse than the ones they treat

140

21%

have saved lives and helped people to function better

490

73%

are a quick fix for people who don't have the inner strength to deal with adversity

63

9%

treat illnesses that can strike anyone

388

58%

are the creation of a greedy pharmaceutical industry that has deceived the public

138

21%

I have no opinion about psychiatric medications

15

2%

Other

223

33%

People may select more than one checkbox, so percentages may add up to more than 100%.

Have you ever taken psychiatric medication? -

Yes

458

65%

No

210

30%

People may select more than one checkbox, so percentages may add up to more than 100%.

Sometimes, patients are seen for brief visits by a psychiatrist for management of their medications and if they need psychotherapy, they see a social worker, psychologist, nurse therapist, or counselor (so-called "split treatment"). What do you think of this practice?

Brief visits with a psychiatrist for medication management typically work well

154

23%

Psychiatrists should spend more time than this with their patients to manage medications

348

52%

When possible, psychiatrists should provide both psychotherapy and medication management to their patients

377

56%

Patients should not see psychiatrists at all: medications should be managed by other professionals such as primary care physicians, nurse practitioners, or specially-trained psychologists

38

6%

I have no significant opinion on this topic

52

8%

Other

161

24%

People may select more than one checkbox, so percentages may add up to more than 100%.

Electronic Health Records (EHRs or EMRs) . . .

should not contain any records of psychiatric illnesses and treatments (including medications) even though that means my primary care doc or ER doc wouldn't know about my meds or condition unless I tell them

89

13%

should have separate and higher protections for mental illness than for other health problems

218

32%

should exist for psychiatry exactly as all other medical records do, with the same protections as for other health condition, because adding special protections increases stigma against mental illness

275

41%

should allow patients to control which information they wish to be shared and with whom for all medical specialties

290

43%

facilitate better communication and improve psychiatric care

261

39%

negatively affect communication and detract from psychiatric care

49

7%

I have no significant opinion about electronic health records in psychiatry

74

11%

Other

94

14%

People may select more than one checkbox, so percentages may add up to more than 100%.

People may select more than one checkbox, so percentages may add up to more than 100%.

Do you feel this survey is balanced and fair? -

Pretty much

431

61%

In the middle

198

28%

Not really

40

6%

People may select more than one checkbox, so percentages may add up to more than 100%.

Comment box for additional comments or suggestions . . .

You're missing the large portion of the population who doesn't read blogs like this. My close friend has very different attitudes toward psychiatry (they are wierd, controlling, just want to push meds, etc.) and she may be more the typical person.You surely didn't think this was a balanced or fair survey. did you? Was that part of your plan?You have to find a way for members of the same family (spouse/parent) who are on the same insurance policy not to see each other's medication/psychiatric treatment records.Lawyers take the name of a medication and then create an attack on the person for ...

I may be mistaken, but I remember the survey indicating that the data would be used in a conference presentation. Occasionally, it seems, the psychiatrists are not all out to get us (sarcasm intended)!

I suspect the percentages supporting electronic medical records would change if patients actually read their psych records. You might want to know what the psychiatrist is writing before you make the records available to other physicians.

Anon#1, I've never been one to shrink (and actually I didn't intend that pun) from criticizing survey methods and non-scientific studies, but I find your complaints about this one particularly strange. Your qualm is that the survey isn't scientific or representative, despite the fact that not only has nobody has claimed that it is, they've specifically explained that it's not?This seems a bit like buying a cherry tomato plant and then later complaining that you're not getting any full-sized tomatoes off of it. (Yup, it's gardening season!)

The survey starts out stating that it was not taken or analyzed scientifically or otherwise. It was just a simple mechanism to get a random group of people together and get their thoughts on psychiatry and mental health. How many people are asked in a public setting to "put up their hand" if they think our president is doing a good job. How many think he is doing a bad job? How many think if he had Senator XYZ as VP he would be a better or worse president? How many don't care? we do it all the time. It is just a mechanism so the people in the room start thinking about the topic in different ways. As someone with mental illness, I found the survey could open our eyes to the factthat psychiatry, psychiatric medicine and treating mental illness is in it's infancy stage and how much more we need to learn.

to the last anonymous: you are right about psychiatry having a long way to go. Most every (not every) psychiatrist I know is quite humble and aware of his limitations. But reflect: looking back, is not every branch of medicine in a place far different from where it was fifty or a hundred years ago? It is that way with science.

The brain is as complex compared to the heart as the space shuttle to a lawnmower. Yet many people get angry with psychiatrists because they don't know more. Others are angry with the way they are treated by certain practioners. The second is understandable. Rarely do you read of people lambasting cardiologists because they do not have better ways (today) of treating heart disease. Or gerontologists because they do not have the fountain of youth.

Five minutes from the cardiologist may be accepted, but much more is expected, often not unreasonably, of psychiatrists.

In a hundred years all medicine will have advanced. But we are here now and we psychiatrists can do only as well as our science and personal abilities allow. Empathy cannot be packaged. It is not in a pill. Sometimes it is vastly more important than medication, yet all the empathy in the world will not do what a little lithium can. Or Prozac. Good psychiatrists know the difference.

So I am also responding to the bitter gauntlet hurled down by anonymous 1. If you expect perfection from us, you will never find it.

I would agree that the first comment was unfair. I recall it being clear the survey was going to be used at the APA conference so I don't think there was anything misleading about that.

That being said, I don't agree with Jesse's assessment about where so much of the anger comes from that is so often directed at psychiatry. I frequently hear this comparison between cardiology and psychiatry made by psychiatrists. I don't think it's a fair comparison.

I think the problems arise when patient's rights are violated, such as when patients are coerced or threatend into signing an informed consent document to be admitted into a psych ward as a "voluntary" patient or to have ECT and so on. You don't see that happening in cardiology - you can either take your lipitor or metoprolol or not, you can either sign the ICD to have an angiogram or not. Nobody is going to threaten you with a stay in a state institution if you say no. I believe a lot times the anger directed at psychiatry comes from people who have experienced the pain of involuntary treatment and are left with more trauma to deal with.

This is getting way off topic but since it was brought up... I really think there would be less anger directed at psychiatry if we erred more on the side of patient rights (like we do with cardiology patients).

One of the problems with (for) psychiatrists rather than, using the previous example, cardiologists, is that the worst thing that will happen from the cardiologist is that one will die. The psychiatrist however has a great deal more power over the lives of some of their clients - including the ability to keep someone locked up and forced to take medication (which often have very bad side effects) or even electroconvulsive therapy, against one's will.

I did not remove any comments. We leave them all unless they are pure spam or contain obscenities.

Thank you to everyone who helped me write the survey-- I think I incorporated almost every suggestion and I showed a slide of the post where I asked readers for input on the survey. I find whole interactive nature of the blog to be really cool!

I do remain a bit perplexed at the confrontation my posts seem to inspire

Dinah, if you don't remove any comments that aren't "pure spam" or obscenities, I think your blog must randomly eat some comments. I stopped reading your blog altogether for awhile after noticing that a couple of my comments had disappeared. While it's usually better to assume computer hiccups rather than malice, I'm dense enough that the "if I don't know why someone is upset, they're probably not upset with me" approach generally leads to people getting really angry at me for ignoring their clear anger at me. Translated onto the internet, that means not always assuming computer problems. I dealt with it by avoiding your blog for awhile.. others might be getting confrontational over it.

I think some of the general hostility in comments is not towards you at all, though. The search for a decent psychiatrist more often than not turns up some really bad ones. When you get a list of 6 doctors from your insurance company, that's the same list everybody else gets. Generally at least a few have stopped accepting insurance and a few more are booked solid; so the one really bad one on the list is the first one anybody can get in to see. It leaves a lot of people with a lot of resentment and not much means of properly expressing it.

I posted a reply to what you just said, Dinah, and it seems to have disappeared. It definitely contained no spam or obscenities, so Blogger must be randomly eating some of your comments. (Not surprising, but certainly annoying!)

"I do remain a bit perplexed at the confrontation my posts seem to inspire."

Dinah,I think it is because there are many people or their loved ones who have suffered as a result of psychiatrists and those who carry out their instructions. A recent public example is the forced electroshock treatments of Elizabeth Ellis in Minnesota who already had received more than a dozen electoshock treatment in Winter of 2011. When she refused to go to more outpatient electroshock appointments, she was locked up as an inpatient and forced to have more. She has been locked up having continuing electroshock since February 18, 2011. Finally a court battle has resulted in her promised release some time this month. This makes me angry and sick inside thinking about it. Electroshock is preferentially performed on aging females and memory loss is a known side-effect. It's not a trade-off I would personally made, yet in California I could be forced to have electroshock.

Personal experiences people have had such as the above cause anger toward the entire profession. Your website is a public forum. As a result of publication of your book, you are now easily found by a wider audience. It is not about the care you personally deliver or the quality and sincerity of your book. There are many wonderful psychiatrists who provide loving care. Until the abuse that patients receive as in-patients stops there will be angry psychiatry "consumers" as the drug companies are fond of calling us.

@atraveller: You guessed it. There were 4 msgs in Blogger's spam filter. I can't figure out why it tripped the filter, as they weren't spammy. Maggie's was not there (unless it was under Anon).

@anon (last one): I've noticed Blogger's spam filter grabbing more comments over past few months. It used to grab 1-2 per month, but it grabbed 4 over past 4 days.-re: insurance networks, I believe many benefit from not updating their list of "participating" providers, thus looking like they have an extensive network. When it happens, it may be negligent or even fraudulent. I know of some states where insurance plans are being reported to the state's attorney general when their provider directory does not match reality. Another avenue is to determine who accredits the insurance plan. For example, if it is URAC then you can file a complaint and they will investigate it. Many states require plans to be accredited, and URAC has standards they must meet to be accredited.

@leslie/anon: re med records, I agree that patients should be able to review their records and choose which to share or not. I'm not sure what to do about providers knowing (or not) that info is missing. With paper records, people just chose not to tell a doc about some prior treatment. Shouldn't they still be able to do that with electronic records? It's their data, after all.

Regarding the formatting of the post, I'll see what I can do to make it more readable.

My last catch-up comment...Jesse's comment is on target, while Leslie's and Sunny CA's hits the nail on the head about our blog also being a place to comment for those who rightly feel harmed by laws that place psychiatrists in the position of forcing people to get care. Personally, I do see situations where forced care "makes sense"' such as someone who is making dangerous decisions based on psychosis. Most people would not let such a person put themselves in harm's way. Much of the arguments occur when there is disagreement as to where to draw this line. I only ask of commenters to not assume that the three of us have bad intentions, just because of their experience with another psychiatrist.

Sunny CA's and Leslie's comments are well taken. Context is important. My own practice does not involve any inpatient, much less involuntary, treatment. So that is not what I was thinking of when I posted earlier. I'm going to give some thought to this subject, that of negative perceptions of psychiatry, and in particular that of involuntary treatment.

Oh, the spam filter--it's Blogger's, not our personal email. I forget it's there, and every now and then check it and release anything that isn't obvious spam. The comments then go to the correct post, but by then, the commenter may well not know---I only recently even realized such a filter exists.

Confrontation: some of it may be about involuntary treatment, but a fair amount is lobbying against the use of medications, even for patients who want them. I rarely hospitalize any one, can't recall ever hospitalizing anyone involuntarily, and none of my patients have had ECT, or at least not in the past decade. In Maryland, I'm not aware that ECT is ever given against anyone's will. Can it be given involuntarily in CA? I would be surprised, I think they've completely outlawed it in parts of the state (or tried) even for people who want it. I have read the links about the woman in Minnesota, and it is very upsetting, but whenever there is such an egregious story, I'm left to wonder what the other side of it is--- when I hear both sides, then perhaps I will have an opinion. At any rate, we Shrink Rappers have not made the laws about involuntary treatment, and I do sympathize with how hard it is to find care---this one is for the insurance companies (maybe they have a blog someone could troll?).

We're just a group of shrinks who work for a living and like having a blog. And we never suggested putting paxil in baby formula, not even once, not even for colicky babies. It's one thing to challenge what we write about-- I agree that's part of the deal-- but sometimes it feels like readers blame us for things we had nothing to do with, and the tone can be a bit hostile at moments, in a way that makes it not-fun.

Roy, it makes sense to me that psychotic patients would need to be protected from making "dangerous decisions" and obviously society wants psychotics to be removed from society. What needs to change is the cruelty of treatment that these patients receive. Also, any treatment that is involuntary ought to not cause permanent brain damage like electroshock does. Inpatients should be allowed visitors at normal hospital visiting hours instead of for one hour in the evening. If relatives were allowing onto the wards I am convinced that some of the patient abuse would cease. The mistreatment continues because it is hidden from view.

@sunny ca: I'm surprised that CA permits involuntary ECT. I don't think Maryland does. I know of patients who had advanced directives stating "when I get severely ill, give me ECT because it's the only thing that works, no matter what I say" and they still couldn't get ECT because they refused it while ill.

As for the visiting hours, at our hospital people are in groups all day, so visiting hours occur after groups and dinner are done. I imagine it is similar at other places so that is probably why they don't allow visitors whenever. But I agree with your point of trying to be more open.

I apologize for jumping to an incorrect conclusion after I saw my comment post and then later disappear. I commented on someone else being unfair, and then I did the same thing.

Maybe I'm just not paying attention, but I have not noticed a lot of people on this blog lobbying against the use of medication for people who want to take them. Those who find them helpful should be free to take them, while those who don't find them helpful or don't want to accept the risks should be free to opt out.

Sunny, I agree with your suggestion about visiting hours. It would lessen some of the fear of patients to have more visiting hours, and also increase the accountability of staff. Staff would be more respectful if there were people around to observe. It would also make for a much less depressing environment to have more visiting hours and less groups. For people who are already depressed listening to a bunch of sad stories all day can end up making them feel worse. Maybe instead of having a one size fits all treatment plan, there needs to be a little more flexibility because people need different things. The best thing you could do for someone who has spent weeks in their apartment depressed and isolated would be to encourage more outside contact from family and friends.

I fear involuntary treatment so much that I literally spent 100 hours writing up my psychiatric advance directive, and had my psychiatrist as one of my witnesses,and had her put a note in my chart that I was mentally competent that day. I make sure that the social workers who make commitment decisions in my rural county know me very well.

ECT was a horrible experience for me, and didn't help one bit. I lost all my memories from 2008except for the teror of waking up not knowing where I was or why I was there. Most of the meds just made me worse (in hindsight, maybe akathisia?), with side effects to boot, and sometimes when I went inpatient, there would be abusive staff (probably burned out).

Psychiatric care has been a total disaster for me, and just made me worse over 15 year of hell. I'm better off cycling thru my bipolar moods than taking pills that do nothing or make me crawl inside.

I am amazed that there are patients who get good results - I literally cannot believe it. I now put those folks in the same category as the people who wear magnets and do colon cleansing. I think psychiatric care just doesn't work, and it is terribly abusive.

You psychiatrists have to eliminate the coercion. A small number of psychiatrists seem to get off on it (not many, a small number, but it has put terrible fear into me). I have always known I had problems, and coercion was never needed, nevertheless, I have been threatened several times when I was there for voluntary care. I don't get it!!!! It is much better now that I am married. My husband does not have mental illness, so the doctors will listen to him.

most of my psychiatrists and all of my therapists and social worker type people have been nice, but it doesn't take too many arrogant psychiatrists to scare the hell out of patients. I cannot trust my current psychiatrist whom I have had 8 years because I fear her. And she is a nice lady. I feel bad that I am so afraid of her.

OK, so there is one person's explanation of why people are against psychiatry. If my husband got results like mine with his diabetes, he would give up treatment too. But his doc doesn't threaten him and his meds work well with only mild side effects.

Someone commented that Jesse must be a good psychiatrist (here or on another post maybe?). He is fantastic--very warm and gentle and caring. His patients are lucky.

When I was in training, our chairman would interview two patients a week--one on 'service rounds' in front of the residents, and one in 'grand rounds' in front of the entire department-- usually inpatients. It sounds horrifying, but patients never seemed to mind. He always began by asking the patient if they were being treated well and there was a big emphasis in our program on being respectful to patients. I've always assumed that people were reasonably kind to the patients because I pity the soul whose patient told the chairman, "my nurse/doctor/etc was abusive to me." As a teaching hospital, there were checks and balances in place that may not happen in community settings. That's not to say that people weren't placed in seclusion or encouraged to take medicines.

Clearly, our treatments help some of our patients some of the time. Some people have conditions that just don't respond to our treatments, or have side effects such that they can't tolerate them. I believe that sometimes the cure is worse than the problem, and if a medication (or therapy) is not helping, it shouldn't be used for that patient.

I do fully understand that patients have awful experiences and there are some really bad shrinks out there. As much as patients hate when psychiatrists make assumptions about them (ie, all people with bipolar disorder must be on lithium for life), I don't like it when readers generalize that one psychiatrist treated them badly, therefore the shrink rappers are horrible and it's fine to be hostile towards them because they deserve it.

"Anti-psychiatry" is not about anger at a single psychiatrist or at a bad inpatient stay, it's a movement that has a move pervasive objection to psychiatry...per antipsychiatry.org:

"Psychiatric drugs are worthless, and most of them are harmful. Many cause permanent brain damage at the doses customarily given. Psychiatric drugs and the profession that promotes them are dangers to your health. "

I just don't see this in my practice-- I see patients who feel helped by medications, and I am often the one encouraging them to try coming off them.

It's not anti-psychiatry to say "I had a bad experience," or "I felt like I was treated poorly and I don't want this to happen again," or "I believe there are measures that can be taken to make an inpatient stay less distressing to those who are distressed by it and here are my ideas." It's anti-psychiatry to say that psychiatry didn't help me and these treatments should therefore not be available to anyone.

The issue of communications from family is soooo complicated. Some readers have expressed anger and feeling disrespected that a psychiatrist would accept a letter from a family member. This will someday be it's own post (My to-blog list is getting huge!). But let me ask it this way: You're terribly worried about a family member, he's up all night long, acting completely out of character, doing odd things, arguing with everyone and people are retreating. You believe this is because of an exacerbation of his illness and you realize he's not telling his doctor the truth---maybe he's missed appointments, maybe you realize he's not taking his medicines, or worse, taking more than prescribed. You call the doctor who refuses to even hear your concerns. How do you feel now? Does this increase your respect for psychiatrists? In my own practice, I've come up with an answer that mostly works....(mostly)...

@jd: thanks@leslie: no biggie. good points on the visiting hours. I like the idea of turning visits into a therapeutic episode somehow. many states and payors have expectations requiring a certain amount of groups or therapies per day, so we don't have free reign on this so much.

@anon: "Why are so many psychiatric patients antipsychiatry?" ... I doubt that there are "so many" who are antipsychiatry, in the way that Dinah described it. I could be wrong, but I do wonder what the proportion is. And we can't really poll for this question, because the results from Shrink Rap readers will no doubt be very different from Furious Seasons readers or from NAMI readers. (For the record, I greatly respect blogs like Furious Seasons. Watchdogs and whistleblowers always play important roles in keeping powers in check.)

I am sorry the last anonymous feels the way she does and still is going to a psychiatrist she does not trust.

I ended up with a terrific psychiatrist I can trust. He always could be trusted, but it took me a couple of years before I did trust him. Anon, is all your distrust well-founded? If so, there are other doctors out there. I know that some of my distrust was my issue.

I did have really bad experiences, though, so understand where the anger and fear are coming from. I researched California's laws, and patients who are involuntarily committed can be prescribed involuntary ECT. The doctors are allowed to order a one month program of ECT then must reapply for the second month's ECT. It sounds like permission is pretty automatic, though, as the committee that approves the ECT is made up of doctors who perform ECT on other patients.

Dinah: In emergencies only family members should be able to send messages. The definition of an emergency is not fixed but would probably your scenario might fall under an emergent emergency, so I see no big problem. The problem lies in family members treating people with psych diagnoses as children. When a person is well but having a bad time at work, lost a cherished pet, things like that, families often believe that it is because of the illness. People with diagnoses have a tough time being able to show emotion without it being labeled pathalogical. Laughing a lot? You must be off your meds. Crying jag? Must be off your meds.

Roy, I didn't think of the # of groups being influenced by insurance. That's an interesting wrinkle I hadn't considered. I guess I just assumed my insurance company would be happy that I started refusing groups. I did give it the college try, though.

Of course inpatient if you resist anything, a nefarious motive is assumed. When in reality, I think it's often the sanest thing to do. I still cringe over the fact that I had to pay for some of that - one group involved a psychotic patient rambling the entire time about a visit with the queen of england the previous day. No one got anything out of that, including the patient who was psychotic. And, then there's recreational therapy which involved gluing pictures from magazines onto construction paper. All I could think of was how I was going to eat what insurance didn't pay.

Resisting that which isn't healthy or feels pathologizing is a good thing, but it gets you labelled noncompliant.

The things that helped were the brief moments in the sunshine during smoke breaks (even though I don't smoke) or sitting and playing cards with someone - healthy adult type activities.